Expat guide to South Africa: health care

In the latest of our expat guides, Peter Pallot outlines the health care and
cover options in the republic.

By Peter Pallot

12:59PM BST 21 May 2010

South Africa has great sights, such as Table Mountain, but health care is deeply divided along state and private lines The gap in standards between private and public health care sectors is as wide in South Africa as any country in the world. Like other nations in Africa, the public sector is under-resourced and over-subscribed. Diagnostic facilities in state hospitals are lacking; wards are crowded.

The private sector shines by comparison. No other African nation comes near to offering these standards of care. They also exceed those in many European centres. Some hospitals in Johannesburg and on the coast are centres of medical excellence, and attract health tourists from outside the continent.

But they are beyond the reach of 80 per cent of the population.

In effect, South Africa epitomises the health care dilemmas evident in many parts of the world, namely

* The private sector has better pay, infinitely better working conditions and enough hi-tech equipment to satisfy doctors' professional needs. Consequently, it has attracted doctors and some nursing staff away from state hospitals – where, arguably, they are more needed.

* At the same time, the cost of private care in South Africa – still reasonable by international standards – is accelerating. Some reports put yearly medical inflation as high as 25 per cent.

* The government wants to get more people to take out private medical cover – not necessarily for ideological reasons, but to ease the burden on the state. The medium to long-term aim is for a social insurance plan, requiring all employees to have cover. This is a key ambition, along with a much-needed drive against HIV/Aids and TB.

Health divide

One in five people have private medical insurance. Their needs are catered for in a good primary care system (no shortage of well-qualified GPs) and a fast-growing hospital sector. There are 200 private hospitals in South Africa (roughly the UK total) even if four in five people cannot afford to use them.

They rely on the public sector, which accounts for only 40 per cent of total health spend in South Africa. In addition, the public sector is not an NHS-style service. Users are charged, although fees can be as little as £4 per appointment for the unemployed.

Spending on medication in the private sector per patient is 13 times as great as the state system. Even allowing for a tendency for drug companies and private hospitals to hike charges in the private sector – while state "bulk buyers" can get a better deal – the difference is stark.

So, overall, it's an unbalanced picture. It emphasises the chasm in provision between those who can afford care to western standards, and those getting by on third-rate services.

As the cost of hi-tech medicine continues to escalate above other inflation measures, it is going to be difficult for South Africa to even things up. Globally, the standards gap between rich and poor countries is increasing, and South Africa appears to be no exception.

On the universal test of a nation's health service, South Africa emerges with 44.2 infant deaths per 1,000 live births, compared to 4.8 deaths on that measure in the UK (which is not among the best of European nations).

Life expectancy in the republic in 2007 was 50.5 years, compared to 79.3 in the UK, according to World Bank research.

Private cover

Private medical insurance is essential for anyone expecting to receive treatment to western standards, unless they opt for the pay-as-you-go route. But that may expose the individual to a sudden, unexpected, drain on cash.

Comprehensive, rather than basic, cover is important. This is so that primary (GP) care is included, along with secondary (hospital) cover.

Exercising the option to see a doctor for basic conditions, or for the regular review and maintenance of a chronic condition is less hassle than going to a hospital every time. It can also be a lot cheaper.

Bupa International, which is among the most active insurance providers in South Africa, does not advocate evacuation cover for those permanently resident there.

Dr Sneh Khemka, the company's medical director, said: "However, we would definitely recommend it for those who may wish to access treatment in Europe, or those who are travelling to other parts of Africa, where standards are poor."

Ambulance transport

South Africa has much higher crime and road accident rates than Europe. Its road network is also worse. Consequently, one's chances of needing an ambulance will be greater than in UK, and the chances of the ambulance not being a road vehicle are very much greater.

Air ambulance transport is very widely used. For instance, a third of emergency admissions at Milpark Hospital, Johannesburg, which specialises in severe trauma, arrive by air. Any decent insurance plan should include an air ambulance benefit. But it's worth checking.

Local insurers

More than 100 insurers will sell you their products, but their ranks are subject to change as the industry is going through a merger and acquisitions frenzy. This has been triggered by legislation requiring insurers to have 25 per cent solvency on reserves.

Discovery Health has a dominant share of insurance. Like most insurers, it insists that hospital treatment is pre-authorised. To help contain premiums, it will cover costs only to pre-agreed limits. If a surgeon charges more than the set tariff, the patient must pay. This arises quite often.

If a policyholder goes to hospital without giving 24 hours' notice, Discovery will repay only 70 per cent of the bill. Smaller providers include SelfMed and MultiMed. Resolution Health is one among a series of new players.

No-frills local health plans

Local schemes – often referred to as "medical aids" – offer, in the main, simple hospital in-patient cover plans. They can be very inexpensive. Premiums may start from around R300 (£25) per month.

However, these schemes have seen some significant price rises in recent years, reflecting steep medical inflation.

This may leave policyholders feeling justifiably "caught" where a claim has been made, and then becomes subject to exclusion when moving to another insurer.

It has been known for the insurer to cancel cover when a policyholder notifies them of future treatment. This leaves the individual without cover. People then face the near-impossible task of finding a company that will take the risk without imposing exclusions, as the condition is then deemed to be pre-existing.

The dictum "you get what you pay for" applies. Many local schemes tightly cap the benefits. In such cases, policyholders have to dip into their own pockets.

Chronic disease

Even though no reputable international insurance company would cancel cover, people with up-market policies can still find themselves exposed once a disease passes from acute to chronic phase. (An acute condition is one which treatment will usually succeed, or will resolve naturally. In chronic disease, no resolution is likely in the foreseeable future and/or treatment will not produce further benefit.)

However, insurers are increasingly offering cover against chronic disease as an "add-on" benefit, or even as "core" benefit, as part of the plan. This can be of great value in cases such as heart failure, and some other cardiac conditions, HIV/Aids, asthma or diabetes. Cover applies only if you develop the chronic condition after buying cover. If you have a medical history, the condition is deemed pre-existing, and is therefore excluded or subject to premium loading.

Aids cover

Cover for HIV/Aids is of particular significance in Africa, which is precisely why insurers have until recently excluded it. As consumer demand grew, so insurers became more positive. But they limited cover to HIV-negative policyholders who had been customers for four or five years.

Another possible exception remains those individuals within large group schemes, usually an employer. Companies with large numbers of staff have been able to get a degree of HIV cover for their employees because insurers want their business and risk is reduced by the "pool" size.

Last December, the UK-based InterGlobal started offering this sort of cover for individuals – there was no wait before cover became good. The facility applies only on the company's top plan Africa UltraCare Select. The annual premium paid by a 40 year-old would be $1,673 (£1,132). And the HIV benefit is tightly capped. Unusually, it is set at lifetime limit of $5,000.

This makes it less attractive than it might appear. Under most plans, benefits are good to a capped sum per policy year. A patient undergoing HIV treatment could breach the lifetime limit in a year.

InterGlobal's Elite plan, along with a basic version (Standard), which does not have the HIV benefit, provides emergency medical evacuation cover. For Standard cover, a 40 year-old would pay $1,092.

Bupa International is the largest provider of international insurance for individuals from, or relocating to, South Africa.

Plenty of other western providers are prospering on the back of their reputations for quality, in South Africa and across sub-Saharan markets. International European companies are increasingly active in the region because of apparent demand for a top range, reliable and transportable insurance package.

Comparing prices between providers is never easy because no schemes are identical. Insurance adviser Stephen Walker, of the Brighton-based Medical Insurance Services, singles out AxaPPP as particularly good value.

From a list of seven top UK international health insurers, Axa is the least expensive. A 30 year-old would pay £1,011 a year for comprehensive cover (broadly inpatient and out-patient) as against £1,538 for ExpaCare's

Execeutivecare plan, the most expensive. Another competitive deal comes from William Russell (Global Health Elite) at £1,049 a year. The Global Select Standard plan from IMG is also inexpensive at £1,027, due to a 15 per cent "starter discount."

For a couple aged 61 and 59 wanting comprehensive cover, Axa is again cheapest (£4,606), followed by William Russell (£5,723) and InterGlobal (£6,412).

Because of the way South Africa's health system works, people buying budget or basic cover are at some risk of incurring significant cost for GP services. Rates for budget cover are generally around a third of the comprehensive premium.

Rewards for healthy living

Insurers are increasingly seeking to encourage their customers to adopt healthier lifestyles. Many insurers use a points system. The policyholder is in line for a premium reduction, or less steep rise, for regularly taking exercise, attending a gym and having medical checks.

Health hazards

HIV/Aids: The World Health Organisation estimates that 5.4 million people over the age 15 in South Africa are carrying the virus that leads to Aids. That equates to more than 18 per cent of the adult population. The prevalence in the UK of HIV is 0.2 per cent..

Other diseases: TB, rabies, malaria and cholera are all prevalent. Malaria is common to Kruger Park and parts of Mpumalanga, Limpopo province and KwaZulu Natal (particularly the Wetlands area around St Lucia).

Cholera outbreaks occur in the poor communities of rural South Africa, especially in Northern KwaZulu Natal, Mpumalanga, and Limpopo provinces.

A recent outbreak occurred across the Limpopo region, flowing from the major outbreak on the Zimbabwe/South Africa border. To avoid cholera, drink or use only boiled or bottled water and avoid ice in drinks. If you suffer from diarrhoea, you should see a doctor without delay.

Measles outbreaks occur from time to time in Kwa Zulu-Natal and Gauteng provinces.

Vaccination: The need for vaccination depends on where you go. You should seek medical advice several weeks before departure.

Official advice

The UK government strongly endorses the need for comprehensive medical insurance – or travel insurance for the visitor. This should include medical evacuation cover.

The Foreign Office says: "You should check any exclusions, and that your policy covers you for all the activities you want to undertake, especially extreme adventure sports or wildlife activities. Remember that failure to declare a medical condition could render a policy invalid."

This piece was originally published in the Telegraph Weekly world edition. Please feel free to add comments and updates using the comments field below, or email us at weeklyt@telegraph.co.uk if any of the information has gone out of date.